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Government says HMOs fail to report bad doctors

Although government studies have shown that tens of thousands of Americans die annually due to medical errors, HMOs don't report incompetent doctors to the National Practitioners Data Bank (NPDB), says the United States Department of Health and Human Services (HHS).

Eighty-four percent of the 1,401 HMOs studied by HHS didn't make a peep about a single "adverse action" to the data bank.

In fact, from 1990 to 1999, 84 percent of the 1,401 HMOs studied by HHS didn't make a peep about a single "adverse action" to the data bank, even though they are required by federal law to do so. The data bank was created in 1986 to protect patients from poorly performing doctors. Although the data bank is not available to consumers, state licensing boards use the information in their reviews of doctors.

With close to 100 million individuals enrolled in HMOs, fewer than 1,000 "adverse action" reports over nearly a decade serves for all practical purposes as "nonreporting," says HHS. The department places much of the blame for this low level of reporting on HMOs that have become little more than "bill paying organizations," focused more on the bottom line than on clinical oversight.

Health plans blame language problem

According to the American Association of Health Plans (AAHP), many HMOs aren't aware of the regulations that require them to tell the government when doctors are disciplined because language contained in the NPDB guidebook concerning the federal reporting requirement is vague. "While the guidebook may contain language requiring hospitals and other health care entities to report directly to the NPDB, to our knowledge health plans have not been notified of any regulatory requirements to this effect," says AAHP President Karen Ignani.

Is the AAHP hiding its responsibilities behind semantics? "We're not hiding behind anything," says AAHP spokesperson Mohit Ghose. "Regulatory language has to be specific." Ghose also points out that the current "litigious climate" may also inhibit accurate reporting. "Until this constant threat is addressed, patient care will continue to suffer," he says.

"Maybe it's people not wanting to admit they're not doing what they're supposed to be doing."

Judy Holtz, a spokesperson for the U.S. Inspector General's office, says she doesn't understand why any members of the AAHP might not understand the reporting requirement since it has been in effect for many years. "Maybe it's people not wanting to admit they're not doing what they're supposed to be doing," she says.

Indeed, the issue of "nonreporting" has been looked at by HHS many times in the past, including a 1995 NPDB study that found about 75 percent of the hospitals in the U.S. had never reported an adverse action to the data bank.

The current report shows not much has changed: 60 percent of the hospitals still have not reported a single adverse event to the data bank. In 1995, HHS also said some hospitals and HMOs "may be de-emphasizing or even avoiding adverse actions against poorly performing physicians and some reportable hospital actions may not, in fact, be reported to the data bank."

"I just don't see why it's such a surprise now," says Holtz.

Issues that need greater attention

Although the government's findings about nonreporting are strongly worded, its summary on the matter does give a nod to the AAHP and calls the association's explanation about possibly confusing language "plausible." In order to clear up any such misunderstandings, HHS has targeted seven issues "that call for greater attention if patients are to be adequately protected." They are:

  • Dealing with unsafe practitioners as part of patient safety efforts.
  • The patient-protection role of managed care organizations.
  • The patient-protection role of physician practice groups.
  • The effectiveness of the procedures that give hospital privileges to doctors.
  • The performance of licensure boards in quality-of-care cases.
  • Managed care organizations' understanding of their reporting responsibilities.
  • Managed care organizations' compliance in reporting adverse actions

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